Cases reported • Spinal Neoplasms

1/34. osteochondroma of the thoracic spine and scoliosis.

STUDY DESIGN: The case of a 16-year-old patient with an osteochondroma in T11 and scoliosis is reported. OBJECTIVE: To describe the treatment of an osteochondroma with scoliotic deformity and the imaging methods used for the diagnosis. SUMMARY OF BACKGROUND DATA: Osteochondromas arising in the vertebral column are rare. However, spinal involvement is found with some regularity because osteochondromas are among the most common benign tumors of bone. methods: The clinical history, plain radiographs, computed tomography, and magnetic resonance imaging, and pathologic findings of the reported patient were reviewed. The medical literature also was reviewed. RESULTS: The patient was treated with surgery in an attempt to remove the tumor and correct the aesthetic deformity. The results were satisfactory, with an improvement of the thoracolumbar scoliosis from 45 degrees to 18 degrees. CONCLUSIONS: Osteochondromas of the vertebral column may cause scoliosis. Computed tomography and magnetic resonance imaging are necessary for evaluating the origin, size, and characteristics of the tumor. In this case, surgical management involved resection of the tumor and correction of the scoliotic deformity.

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2/34. Spinal epidural hemangioma related to pregnancy.

We report the case of a 39-year-old woman with adolescent idiopathic scoliosis presenting with myelopathy secondary to a spinal epidural hemangioma. MRI showed an epidural soft tissue mass within the spinal canal between T5 and T9 with severe spinal cord compression. Symptoms had a temporal relationship to her pregnancy. Surgical removal of the epidural hemangioma rapidly relieved her symptoms and neurologic deficits. Follow-up examination 2 years later demonstrated normal motor and sensory function, without any neurologic sequelae or progression of deformity.

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3/34. Progressive spinal lordosis after laminoplasty in a child with thoracic neuroblastoma.

Laminoplasty has been advocated increasingly after spinal tumor excision in children. Results have shown that it offers the required decompression, while maintaining spinal stability and the integrity of the posterior vertebral elements. To the authors' knowledge, there has been no description of a progressive lordotic deformity of the thoracic spine after this procedure. A case of an 8-year-old boy with thoracic neuroblastoma developing progressive thoracic lordosis after laminoplasty is reviewed, and a possible cause is suggested. Discussing this potential complication with parents and the patient, and following up with regular clinical and radiographic assessments is advised.

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4/34. Desmoid tumor of the spinal canal causing scoliosis and paralysis.

STUDY DESIGN: This report describes a case of successful surgical excision of an intrathoracic paraspinal desmoid tumor with an intraspinous extension causing scoliosis and paralysis in a 12-year-old girl. OBJECTIVES: The purpose of this report is to illustrate the potential spectrum of disease of a desmoid tumor and to make physicians aware of the rare possibility of an intraspinal extension of a paraspinal desmoid tumor. SUMMARY OF BACKGROUND DATA: Surgical excision of desmoid tumors in the pediatric population is the standard of care for initial treatment. There have been no clinical reports in the spine literature of a desmoid tumor causing scoliosis or of a desmoid tumor with an intraspinous extension causing paralysis. methods: The tumor was decompressed from a posterior approach followed by an anterior resection and an anterior spinal fusion. Two weeks later a posterior spinal fusion was performed to correct the spinal deformity. The patient also received radiation therapy after surgery for 5 weeks. RESULTS: The patient tolerated the procedure well, has been free of recurrence for 9 years, and is currently doing well. CONCLUSION: This case report should help expand the understanding of the spectrum of this uncommon tumor.

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5/34. Lumbar disk pseudotumor: an unusual presentation of lumbar spinal fracture and stenosis.

We present an unusual case of a primary lumbar disk-space mass that presumably developed secondary to a chronic hyperextension spinal fracture associated with spinal stenosis. This injury resulted in the appearance of a lumbar intervertebral disk-space mass or pseudotumor. The pseudotumor most likely resulted from a prior spinal fracture, leading to a fused hyperextension deformity in a patient with underlying chronic degenerative spinal disease.

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6/34. Clinical evaluation of Luque's segmental spinal instrumentation for upper cervical metastases.

We reviewed clinical data from eight patients with upper cervical metastases who were treated with an occipitocervical fusion procedure using Luque's segmental spinal instrumentation with a fan-shaped rod. All patients had diffuse involvement of the entire anterior vertebral body, extreme instability at C1/2, and severe preoperative neck pain, but no neurological deficits. This procedure provided significant postoperative pain relief, with only one patient experiencing deterioration. The activities of daily living (ADL) levels of four patients improved; ADLs in four patients who were severely impaired were unchanged. Even though tissue destruction continued after surgery, this procedure prevented further deformity and instability. There were two major surgical complications: respiratory quadriplegia and hydro-cephalic coma. Great care must be taken to avoid these problems. Of the various instrumentation possibilities now available, we strongly advocate consideration of this particular stabilization procedure for upper cervical metastases to provide dying patients with an optimal quality of life during their final days.

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7/34. Multiple vertebral metastases from malignant cardiac pheochromocytoma--case report.

A 27-year-old male presented with a very rare metastasis to the vertebral body from a cardiac pheochromocytoma manifesting as a pathological fracture of the C-4 vertebral body that occurred while playing golf. The patient was initially treated with hard collar fixation. gallium scintigraphy demonstrated multiple hot spots in the mediastinum, the frontal bone, the vertebral column, and the rib. magnetic resonance imaging of the chest delineated a cardiac tumor. The patient underwent biopsies of the cardiac and the frontal bone lesions. The diagnosis was malignant cardiac pheochromocytoma with multiple bone metastases. Initial irradiation of the cardiac and the vertebral lesions was followed by surgical intervention to the cervical spine to prevent aggravation of the kyphotic deformity and spinal cord compression. Preoperative embolization of the feeding arteries was followed by C-4 corpectomy, iliac bone grafting, and anterior titanium plating fixation. The patient was discharged and returned to work. However, 20 months later, he died of a metastatic brain lesion with systemic tumor progression.

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8/34. quadriplegia in a 10 year-old boy due to multiple cervical neurofibromas.

STUDY DESIGN: A case report of a child with quadriplegia as a result of neurofibromatosis type I who had cervical laminectomy for spinal cord decompression followed by occipitocervical instrumentation is described. OBJECTIVES: To describe the consequences of severe neurofibromatosis type I and an effective surgical technique of occipitocervical instrumentation. SUMMARY OF BACKGROUND DATA: Neurofibromatosis type I is one of the most commonly inherited genetic disorders in the human population. Extensive intraspinal involvement by neurofibromas can cause significant distortion of normal spinal structure as well spinal cord compression. Extensive laminectomy (with subsequent risk of postsurgical kyphosis) is often required for adequate decompression of the spinal cord. methods: The clinical and radiographic presentation of a child with severe neurofibromatosis type I resulting in quadriplegia is described. The severe neurologic deficit was caused by compression of the spinal cord by intraspinal neurofibromas. Extensive laminectomy was required to adequately decompress the spinal cord. Occipitocervical fusion from the occiput to C6 was done to stabilize the spine and prevent future kyphosis. RESULTS: decompression of the spinal cord led to complete neurologic recovery, and instrumentation of the cervical spine was successful in preventing the development of postlaminectomy kyphosis in this pediatric patient. CONCLUSIONS: The reported case emphasizes the need for treating acute neurologic symptoms caused by spinal cord compression in neurofibromatosis type I as well as addressing the future risk of spinal deformity following laminectomy.

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9/34. Vertebral body replacement with an expandable cage for reconstruction after spinal tumor resection.

OBJECT: The authors report their clinical experience with expandable cages used to stabilize the spine after vertebrectomy. The objectives of surgical treatment for spine tumors include a decrease in pain, decompression of the neural elements, mechanical stabilization of the spine, and wide resection to gain local control of certain primary tumors. Most of the lesions occur in the anterior column or vertebral body (VB). Anterior column defects following resection of VBs require surgical restoration of anterior column support. Recently, various expandable cages have been developed and used clinically for VB replacement (VBR). methods: Between January 2001 and June 2003, the authors treated 15 patients who presented with primary spinal tumors and metastatic lesions from remote sites. All patients underwent vertebrectomy, VBR with an expandable cage, and anterior instrumentation with or without posterior instrumentation, depending on the stability of the involved segment. The correction of kyphotic angle was achieved at an average of 20 degrees. Pain scores according to the visual analog scale decreased from 8.4 to 5.2 at the last follow-up review. patients whose Frankel neurological grade was below D attained at least a one-grade improvement after surgery. All patients achieved immediate stability postsurgery and there were no significant complications related to the expandable cage. CONCLUSIONS: The advantage of the expandable cage is that it is easy to use because it permits optimal fit and correction of the deformity by in vivo expansion of the device. These results are promising, but long-term follow up is required.

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10/34. Image-guided surgery in resection of benign cervicothoracic spinal tumors: a report of two cases.

BACKGROUND CONTEXT: Osseous spinal tumors are an uncommon cause of persistent axial pain and muscle spasm, but even benign lesions may grow to cause deformity or neurological signs.Traditional treatment approaches to resection can be debilitating even when the tumor is benign. PURPOSE: Emerging technologies allow surgeons to diagnose and treat osseous neoplasms while minimizing the collateral damage caused by surgical exposure and tumor excision. STUDY DESIGN: Technical considerations are presented through two cases of benign osseous neoplasm occurring in the cervicothoracic spine of competitive athletes, demonstrating the meth-ods used to provide effective treatment while maintaining maximal functional capacity. methods: Stereotactic imaging and intraoperative guidance was used as an adjunct to tumor care in these patients. Used in combination with minimally invasive, microsurgical techniques,stereotactic guidance localized and verified excision margins of benign vertebral lesions, minimizing soft tissue trauma and collateral damage. RESULTS: Computer-assisted stereotactic localization allowed us to successfully ablate these lesions from their anatomically challenging locations, without disrupting the shoulder girdle or neck musculature, and without extensive bony resection. CONCLUSIONS: Image guidance can accurately localize and guide excision of benign vertebral lesions while minimizing soft tissue trauma and collateral damage, allowing patients a rapid and complete return to high-demand function.

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